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Introduction In its recent World Report on Vision, the WHO called for an updated approach to monitor eye health as part of universal health coverage (UHC). This project sought to develop a consensus among eye health experts from all world regions to produce a menu of indicators for countries to monitor eye health within UHC. Methods We reviewed the literature to create a long-list of indicators aligned to the conceptual framework for monitoring outlined in WHO’s World Report on Vision. We recruited a panel of 72 global eye health experts (40% women) to participate in a two-round, online prioritisation exercise. Two-hundred indicators were presented in Round 1 and participants prioritised each on a 4-point Likert scale. The highest-ranked 95 were presented in Round 2 and were (1) scored against four criteria (feasible, actionable, reliable and internationally comparable) and (2) ranked according to their suitability as a € core’ indicator for collection by all countries. The top 30 indicators ranked by these two parameters were then used as the basis for the steering group to develop a final menu. Results The menu consists of 22 indicators, including 7 core indicators, that represent important concepts in eye health for 2020 and beyond, and are considered feasible, actionable, reliable and internationally comparable. Conclusion We believe this list can inform the development of new national eye health monitoring frameworks, monitor progress on key challenges to eye health and be considered in broader UHC monitoring indices at national and international levels.
A two-round, prioritisation exercise was undertaken between February and April 2020 using an online survey platform (www.qualtrics.com). All panellists’ responses were de-identified throughout, however, individuals were provided the option to join a study authorship group. A project steering group (the co-authors) was convened to guide the development of the initial long-list of indicators, nominate panellists from a network of global eye health experts, review indicator scoring and develop the final menu. We aimed to recruit panellists from all Global Burden of Disease (GBD) Super Regions,13 with equal numbers of men and women per region. In total 74 out of 84 invited panellists participated in Round 1 and 72 went on to complete Round 2 (response rate after Round 2, 85.7%). Men were 59.7% of the Round 2 panel, similar to the proportion among all invitees. Eleven members of the steering group participated, five from a ‘global’ (non-Regional) perspective. Thirty-nine countries and all GBD Super Regions had participants in both rounds and 85% of the Round 2 panel represented low-income or middle-income countries (table 1). Round 2 panellists most frequently reported their roles within eye health as ‘management/leadership’ (25.0%), ‘epidemiology’ (12.5%), ‘clinician/practitioner’ (12.5%), ‘eye health services research’ (9.7%), ‘government/Ministry of Health’, ‘clinical research’ and ‘international institution’ (all 6.9%). Round 2 response rate among invitees by Global Burden of Disease (GBD) Super Region and sex A long-list of indicators was compiled with reference to previously proposed eye health indicators and existing international health and health systems indicator lists, adapted for relevance to the eye health sector where necessary. This long-list was mapped to the domains of measurement of HIS used in the World Report on Vision (adapted from the 2012 WHO Framework and standards for country health information systems) (figure 1). When panellists were invited to participate, they were asked to suggest additional indicators for consideration. The steering group reviewed all indicators identified, only excluding obvious duplicates in order to avoid biassing the pool of potential indicators. At the end of this process 200 indicators were included (online supplemental appendix 1). Domains of measurement of health information systems (reproduced from the World Report on Vision). bjophthalmol-2020-318481supp001.pdf Panellists scored the indicators based on perceived priority in their context. Priority was scored from 1 to 4 on a Likert scale, with 1 representing the lowest priority (‘no need to collect’) and 4 the highest priority (‘essential to collect’) (online supplemental appendices 2 and 3). A fifth option, (0 = ‘redundant’) was included to allow for the fact that the long-list had not been heavily edited and some overlap of indicator concepts was possible. A priority score for each indicator was calculated by summing the products of two dimensions: the Likert scale score (1–4) x the number times each indicator received that score. bjophthalmol-2020-318481supp002.pdf At the end of Round 1, an initial threshold for continued inclusion was set at or above the median score. Indicators scoring in the top half were merged where there was sufficient overlap in concepts to do so. Indicators not scoring in the top half were reviewed to determine if any concepts deemed essential to score in Round 2 had been omitted and should be included to ensure representation (online supplemental appendices 2 and 3). In total, 95 indicators were forwarded to Round 2. Each of the 95 indicators were scored against four new criteria. The panel were asked to indicate their agreement on a 4-point Likert scale (1 = ‘strongly disagree’, 2 = ‘disagree’, 3 = ‘agree’, 4 = ‘strongly agree’) as to whether each indicator was feasible, actionable, reliable and internationally comparable (table 2). In addition, the panel selected 10 indicators they considered to be ‘core’ indicators, described as those which all countries could be encouraged to adopt. These were ranked 1 (most important) to 10. Criteria used to score Round 2 indicators Scores were calculated in the same way as Round 1. Each indicator was scored on the criteria separately and a composite score of all four was calculated, with all criteria weighted equally. Each indicator was assigned a rank position from 1 to 95 for each of the four criterion and the overall composite score. The ranking of indicators 1 to 10 as core indicators was calculated in a similar way: a vote for first place awarded 10 points, second place awarded 9 points and so on. Points were multiplied by the number of times an indicator received that vote position for an overall core score (online supplemental appendices 2 and 3). A ranking of 1 to 95 was given based on this scoring and this ranking was used in all subsequent analysis. Indicators with the same score were ranked equal. We arrived at a list of 30 priority eye health indicators by ranking the Round 2 selections using two metrics: We plotted the core and composite scores against each other and selected the 30 indicators that scored most highly by both ranking methods, by expanding the ‘gating’ equally along both axes until the selected area included 30 indicators (online supplemental appendices 2 and 3). The selected indicators, therefore, scored relatively highly for both. Starting with the top 30 indicators from Round 2, we developed the detailed indicator menu presented in box 1. In this step we aimed to: Equity statement All indicators summarising population-based and eye care facility-based data should report metrics disaggregated by key equitydimensions of sex, place of residence (PoR), socioeconomic position (SEP) and disability status, where available. Additional options, suchethnicity or marital status, can be recorded by countries as appropriate. Inputs and processes Governance G1 Eye health is integrated into the national health strategy/plan (or the relevant specific plan, for example, non-communicable diseases) ► G1.1 National health plan includes human resources for eye care (Y/N) ► G1.2 Eye health is integrated into the plans, policies and budget of other initiatives such as: – G1.2.1 National essential package of health services (Y/N) – G1.2.2 Primary healthcare (Y/N) – G1.2.3 Maternal and child healthcare (Y/N) – G1.2.4 Diabetes care (Y/N) – G1.2.5 School health programmes (Y/N) – G1.2.6 Healthy ageing programmes (Y/N) ► G1.3 National eye health policies, plans and programmes refer to a multisectoral approach/engagement with other sectors (Y/N) – If a national eye health strategy/ plan is unavailable or not up-to-date, record as N G2 Is the national eye health plan informed by recent evidence (Y/N): ► G2.1 Time since cited population-based data was collected (in months/years) ► G2.2 Time since cited Eye Care Service Assessment Tool (ECSAT) data was collected (in months/years) Finance F1 Eye health is integrated into the national health budget (Y/N) – Requires a working group to develop sub-indicators and metadata F2 Eye health is included in national health finance pooling mechanism (Y/N) – Scaled response based on scoring outcomes of sub-indicators in ‘checklist’ If yes, the range/number/list of services addressing leading causes of vision impairment (VI) included: ► F2.1 Outpatient consultation (Full/Partial/No) ► F2.2 Cataract (Full/Partial/No) ► F2.3 Refraction services (Full/Partial/No) ► F2.4 Glaucoma medication/surgery (Full/Partial/No) ► F2.5 Diabetic retinopathy – laser/anti-vascular endothelial growth factor (VEGF) (Full/Partial/No) F3 Proportion of population covered via national health finance pooling mechanisms that includes eye care services: ► F3.1 Proportion covered for: Outpatient consultation ► F3.2 Proportion covered for: Cataract ► F3.3 Proportion covered for: Refraction services ► F3.4 Proportion covered for: Glaucoma medication/surgery ► F3.5 Proportion covered for: Diabetic retinopathy – laser/anti-VEGF Infrastructure I1 Eye health facility density and distribution, disaggregated by: ► I1.1 Primary ► I1.2 Secondary ► I1.3 Tertiary ► I1.4 Low vision services – By PoR (urban/rural), total numbers (public and private) per million population – Additional subnational administrative or geographical divisions as relevant to setting – Additional dimension: Access to primary eye care and cataract surgery via global positioning system data and geospatial modelling I2 Percentage of neonatal units providing screening for retinopathy of prematurity nationally Supply chain SC1 Pharmaceuticals specifically for eye care on the National Essential Medicines List – Total number and proportion compared with a normative standard for eye health pharmaceuticals (eg, WHO or International Agency for the Prevention of Blindness list) Information INFO1 Existence of a National Health Information System that includes eye care service data (Y/N) Eye health workforce HR1 Eye health worker density and distribution, disaggregated by: ► HR1.1 Ophthalmologist ► HR1.2 Optometrist ► HR1.3 Ophthalmic nurse ► HR1.4 Other allied ophthalmic personnel (as relevant to country) – By PoR (urban/rural), total number per million population, and by age groups and sex – Additional subnational administrative or geographical divisions as relevant to setting – Additional dimension: 5-year trends per cadre HR2 Is Primary Eye Care integrated into the national Primary Healthcare training (if applicable)? (Y/N) Outputs Access AC1 Cataract surgical rate – Total number per million population and including variation in rate across urban/rural or districts – Additional dimension: 5-year trend in cataract surgical rate – Additional dimension: Surgical case-mix in terms of preoperative visual acuity Quality and safety Q1 Cataract surgical outcome (visual acuity) – Proportion of eyes with a ‘good’ outcome (6/18 or better) – Proportion of eyes with a ‘poor’ outcome (worse than 6/60) Q2 Number of priority eye conditions with quality of care/clinical practice guidelines endorsed by relevant regulatory bodies ► Q2.1 Cataract (Y/N) ► Q2.2 Refractive error (Y/N) ► Q2.3 Glaucoma (Y/N) ► Q2.4 Age-related macular degeneration (Y/N) ► Q2.5 Diabetic retinopathy (Y/N) ► Q2.6 Child eye health (Y/N) Responsiveness/affordability AF1 Median (range) of out-of-pocket payment made for cataract surgery as a proportion of median monthly household (or individual)income – Report median and mean payment made at point of service (excluding transport, accommodation, sustenance) – Disaggregated by provider type (government/public, private for profit, private non-governmental organisation/charity) – Additional dimension: proportion reported for poorest vs wealthiest quintiles Outcomes Coverage C1 Cataract surgical coverage and effective cataract surgical coverage – CSC (cataract surgical coverage), eCSC (effective CSC), ‘quality gap’ reported, disaggregated by age, sex, SEP, PoR as available C2 Refractive error coverage and effective refractive error coverage – REC (refractive error coverage), eREC (effective REC), ‘quality gap’ reported, disaggregated by age, sex, SEP, PoR as available C3 Coverage of diabetic retinopathy screening of all people with diabetes (at the frequency recommended in national guidelines) – Requires a working group to develop complete indicator metadata – Disaggregated by age, sex, SEP, PoR as available C4 Coverage of school eye health programmes for schools nationally – Proportion of schools receiving screening in the past 12 months – Disaggregated by primary and secondary schools Impact Improved outcomes P1 Prevalence of VI ► P1.1 Distance VI prevalence, by WHO categories ► P1.2 Near VI prevalence, by WHO definition – From population-based surveys, disaggregated by age, sex, SEP, PoR as available P2 Cause-specific prevalence of VI – Prevalence of vision-impairing priority eye conditions from population-based surveys, disaggregated by age, sex, SEP, PoR as available ► P2.1 Avoidable blindness/severe VI/moderate VI/mild VI prevalence disaggregated by age, sex, SEP, PoR as available – Aggregated from VI causes assigned in surveys P3 Prevalence of childhood VI and blindness – Blindness/severe VI/moderate VI/mild VI from population-based or key-informant surveys, disaggregated by age, sex, SEP, PoR as available No major edits to key concepts were undertaken. This process is summarised in figure 2. Flowchart describing the process undertaken to develop the eye health indicator menu.
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